Citation Nr: 21042472 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 10-18 370 DATE: July 13, 2021 ORDER Entitlement to service connection for bilateral carpel tunnel syndrome is denied. REMANDED Entitlement to a rating in excess of 10 percent for post-operative status repair right medial collateral ligament of the knee prior to March 5, 2019 is remanded. Entitlement to an initial rating in excess of 10 percent for traumatic arthritis with decreased flexion and pain of the right knee prior to March 5, 2019 is remanded. Entitlement to a total disability based on individual unemployability (TDIU) is remanded. FINDING OF FACT The preponderance of the evidence is against finding that bilateral carpel tunnel syndrome began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for bilateral carpel tunnel syndrome are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1975 to October 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the October 2009, March 2010, and December 2012 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the issues on appeal, and service connection for a left knee disability, in June 2018 and September 2020. A February 2021 rating decision awarded service connection for osteoarthritis of the left knee. That matter is no longer before the Board. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Entitlement to service connection for bilateral carpel tunnel syndrome is denied. The Veteran contends his bilateral carpal tunnel syndrome (CTS) onset in service and continued since. He asserts that his military occupation specialty (MOS) supply clerk, required a lot of writing, typing, lifting, handling which caused his CTS. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of bilateral CTS, and there is an in-service treatment note for right wrist pain, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of bilateral CTS began during service or is otherwise related to an in-service injury, event, or diseases, to include his treatment and or MOS duties. Turning to the evidence of record, an August 1977 service treatment note indicates that the Veteran had a sudden onset of pain in his right arm, moderate edema of the wrist, hand and right forearm, and tenderness over the wrist. He was treated with an ace wrap and sling. X-rays from that day revealed no fraction or dislocation. A January 1994 private orthopedic treatment note indicates that the Veteran was seen for treatment after suffering a work injury. The Veteran who worked as a mail carrier, reportedly fell on a porch and on his left arm. He subsequently complained of persistent pain, some numbness and tingling down into his hand. On physical examination, it was noted that there was localized tenderness and swelling over the ulna about 3-4 cm distal to the olecranon. Neurologic examination of the hand showed that it was fine. X-rays revealed no evidence of a fracture and the impression was, left arm contusion. The Veteran's arm was placed in a splint. A July 2004 VA emergency note indicates that the Veteran was seen with complaints of intermittent numbness and tingling in the left arm, which he noted was ongoing for about three weeks. The VA physician noted the assessment as probably cervical radiculopathy, not consistent with carpal tunnel syndrome, and probably reactive lymphadenopathy. Private treatment notes from the Veteran's chiropractic clinic in October 2010 indicate that the Veteran was being treated for his neck, upper shoulder, and mid back pain but also complained of tingling in the upper arm that "started about a week ago" and recently worsened. A diagnosis was not noted for the arm. A March 2011 private orthopedic treatment note indicates that the Veteran suffered another work injury, this time to his right side. While delivering mail, the Veteran reportedly slipped on a wet porch and fell on his right outstretched hand. He had some immediate discomfort but did not notice any swelling. The Veteran was provided with a splint but continued to have discomfort and pain in the right wrist. The Veteran's diagnosis was right wrist sprain and tendinitis. The Veteran received physical therapy with this facility through June 2011 and continued to complain of pain and discomfort. Upon returning to work, he continued to wear a wrist brace because he had difficulty with heavy packages. In November 2011 the Veteran returned to the private orthopedic facility for treatment with complaints of right-hand pain and numbness. He indicated that he had a little numbness after the initial fall earlier that year but associated it with some of the swelling he had from the injury. He reported that he was still having intermittent tingling as before in June. His new diagnosis was right median neuritis, possible compressive neuropathy. It was noted that the right wrist sprain and tendinitis were resolved. The orthopedic clinic ordered an electromyography (EMG) and nerve conduction study to evaluate the right wrist for compressive neuropathy. In February 2012, the Veteran was seen for his right wrist EMG and nerve conduction at the same private orthopedic clinic. The conclusion rendered an abnormal study. Motor nerve conduction velocities of the upper extremities bilaterally were noted to be slowed. They represented a mild metabolic peripheral neuropathy. It was noted that the Veteran reported that he "does have a little tingling and numbness at times" in the left upper extremity. The Veteran's private physician reported that he had mild carpal tunnel syndrome. The Veteran underwent a VA peripheral nerve examination in November 2012. There, he reported the onset of his right wrist condition as resulting from a fall in January 2012. The Veteran described trying to break the fall with his right hand and injuring his wrist. He subsequently received treatment from a private clinic which included an EMG and was diagnosed with CTS. The Veteran reported that he started having pain and numbness in his right hand since January 2010. He also reported that he had been having problems with his right wrist for the last 20 years with off and on numbness but his (recent) injury aggravated his right wrist pain and numbness. The VA examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale indicated that the Veteran was seen for fasciomyositis in August 1977 during active duty, but it healed without any residuals as there was no evidence of any wrist problem mentioned in service treatment records afterwards. During his Board hearing in March 2018, the Veteran testified that he was diagnosed with left wrist CTS in 2010 and right wrist CTS in February 2012. He described performing activities such as writing, typing, a lot of lifting, handling a lot of things, gripping, and grabbing due to his MOS. He testified that both of his wrists were giving him "a little bit of problem" during service and he noticed pain, some knotting in his hands and wrist. He testified that he started inquiring about his wrist condition because it was something that kept recurring, he was getting a lot of pain in his writs and hands and was trying to figure out why. In June 2018, the Board remanded the Veteran's CTS claim for a new VA addendum opinion. It was noted that at the time of the Veteran's November 2012 examination, his private treatment records were not of record and the examiner did not provide an opinion for the Veteran's left wrist. Pursuant to the Board's remand, the Veteran was afforded a VA examination in September 2019. At this examination, the Veteran reported the date of onset for his CTS as 2014. He indicated that he began having problems with gripping in the right and left hands. It was noted that an evaluation revealed bilateral CTS and the Veteran declined surgery. The Veteran indicated that his condition had worsened since onset and described current symptoms as a weak grip in both hands, pain and numbness in both hands if using them a lot or while asleep. It was noted that the Veteran regularly used braces for both wrists at all times to prevent tingling and pain. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale was that there were no right or left carpal tunnel syndrome-like complaints until 2014. As this opinion was based on inaccurate facts and did not consider the Veteran's lay contentions, the Board remanded for a new VA addendum in September 2020. Pursuant to this remand, the Veteran was afforded a new VA examination in February 2021. The examiner opined that the Veteran's right and left carpal tunnel syndrome was less likely than not related to an in-service injury, event, or disease, including the complaint noted in service and his occupational duties. The examiner explained in the rationale that there was no evidence of recurrence, progression, chronicity, residuals sequelae of the bilateral CTS to support a link to service. The examiner furthered that prior to 2012, there were no symptoms or diagnoses, noting that the Veteran's symptoms started and were subsequently diagnosed in February 2012, after he fell and injured his wrists in March 2011. The February 2021 VA opinion establishes that the Veteran's bilateral CTS is not at least as likely as not related to an in-service injury, event, or disease, including his in-service treatment for pain or occupational duties as a supply clerk. The examiner's combined opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Indeed, aside from the Veteran's lay reports which have been inconsistent, the evidence of record does not reflect that the Veteran had a wrist condition that persisted since service. Thus, the VA examiner's findings of a lack of recurrent wrist symptoms since service appear to be consistent with the credible evidence of record. There is no clear indication that he was in fact diagnosed with CTS in 2010. What is clear, is that after suffering his on-the-job injury in 2011, the Veteran's pain and symptoms continued for almost a year, even after physical therapy ended. This led to the Veteran returning to the same providers in 2012, who treated his 2011 work injury. Upon their recommendation, he underwent an evaluation that included an EMG, which revealed that mild carpal tunnel syndrome. Thus, the February 2021 VA examiner accurately described the Veteran's lack of a diagnosis, particularly, CTS, prior to 2012 and lack of chronicity since service. The previous VA opinion provided in November 2012 regarding the right wrist is generally consistent with the most recent VA nexus opinion. The November 2012 VA examiner reasoned that the Veteran's in-service treatment for his right wrist healed without any residuals. Post-service, the Veteran began having problems with numbness in both hands 20 years ago and was diagnosed with bilateral CTS recently, with the right hand worse than the left. This was more than 10 years after his discharge from service. While this examiner did not have access to the Veteran's private treatment record, it is clear that the Veteran's files were reviewed, and his lay reports were considered in the VA examiner's medical opinion. This is demonstrated by the fact that although the RO specifically requested an opinion for the right wrist, the VA examiner also addressed the left wrist, noting the Veteran's medical history; specifically, that CTS was worse in the right wrist than left wrist. Further, based on a review of the file, the Veteran's report that his current bilateral CTS symptoms have been recurrent since service is not credible. Credibility is a factual determination as to whether a witness is worthy of belief. Generally, the credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996) (table). As noted above, the Veteran has made inconsistent statements regarding the onset of his bilateral CTS symptoms, which has caused the Board to question the veracity of his lay reports. For example, the Veteran testified that he believed his symptoms started in-service and that he did a lot of typing, "computer things" as part of his job. However, the earliest post-service treatment show he related his wrist symptoms to a post-service work injury. At this time, and no time prior to the Veteran's June 2012 service connection claim, did he report that the numbness and tingling he felt in the left or right hand/wrist was similar to that which he felt during service. There was no reference to, or association made by the Veteran between his military service or duties performed as a supply clerk and his diagnosed condition until this claim. Notably, the Veteran himself, gave an onset of 20 years at his November 2012 VA examination. This would reflect 1992, which is 15 years after the Veteran's discharge from service. The Veteran believes his bilateral CTS is related to an in-service injury, event, or disease. While the Veteran is competent to report having experienced symptoms of pain, numbness, and tingling since service, as noted, the Board does not find his report credible. Moreover, he is not competent to link his current diagnosis of carpal tunnel syndrome to service. That determination is medically complex in nature, as it requires knowledge and interpretation of complicated diagnostic medical testing, such as what was performed in February 2012, by medical professionals. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners' medical opinions. In sum, the preponderance of the credible and competent evidence is against the claim, the benefit of the doubt doctrine is not for application. Service connection for bilateral carpal tunnel syndrome is not warranted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for post-operative status repair right medial collateral ligament of the knee prior to March 5, 2019 is remanded. 2. Entitlement to an initial rating in excess of 10 percent for traumatic arthritis with decreased flexion and pain of the right knee prior to March 5, 2019 is remanded. In June 2018 and September 2020, the Board remanded these issues for further development. While further delay is regrettable, another remand is necessary because there has not been substantial compliance with remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Following the most recent remand, the Veteran was afforded a VA examination in February 2021; however, the examiner did not provide a retrospective opinion as directed. Rather, the examiner indicated that, she was "unable to comment as [the] [V]eteran had a right knee replacement March 2019 with good healed scar and mild residuals." Unfortunately, this opinion is also insufficient as the examiner did not attempt to estimate the additional functional loss during flare ups based on the information provided by the Veteran or medical records available. A VA examiner is to estimate functional loss based on the Veteran's descriptions of his additional loss of function during flare-ups, gleaned from his medical records, or discerned other sources available to the examiner. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 3. Entitlement to a TDIU is remanded. The Veteran asserts he is unemployable because of his service-connected right knee disabilities. The Board has remanded the appeal for an increased rating for the right knee, thus, these matters are inextricably intertwined. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician for the Veteran's right knee disability. Based on the examiner's review of the relevant medical records and the Veteran's statements, the examiner is asked to express a retrospective opinion concerning functional loss due to flare-ups experienced in the right knee. The retrospective opinion must address the Veteran's prior report experiencing flare-ups of his right knee disability during the 2009, 2012, and 2013 VA examinations. In doing so, the examiner must express the Veteran's estimated functional impairment in terms of the degrees of additional range of motion loss. The examiner is advised that the inability to provide an opinion without resorting to speculation must be based the limitation of knowledge in the medical community at large and not a limitation - whether based on lack of expertise, insufficient information, or unprocured testing - of the individual examiner. D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.